MEDICARE: DR. JACOB JOSE KURUVILLA DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DS041245	PA
2	122300000X	Dentist	33117	TX

General Provider Information

NPI Number	:	1164952032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACOB JOSE KURUVILLA DMD

Provider Business Mailing Address
First Line	:	11613 N CENTRAL EXPY STE 111A
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75243-3808
Country	:	US
Telephone Number	:	631-742-9840
Fax Number	:

Provider Business Practice Location Address
First Line	:	1110 S CESAR CHAVEZ BLVD APT 3050
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75201-6089
Country	:	US
Telephone Number	:	631-742-9840
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2017
Last Update Date	:	07/21/2022

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